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IM
APPLICATION FOR BLIND OR DISABLED PERSON'S
DEDUCTION FROM ASSESSED VALUATION
State Fortn a3710 �RS / 6-03)
Prescnbed by the Department of Local Govemment Finance
COUNTY TOWHSHIP YEAR
� �
11 1t�
I^'�-�ation coniained in Nis dowment is CONFIDENTIAL pursuant to IC 12-1-1-7(n) and IC 6-7.1-12-12(b). ��
�ucrioNS: OCT 21 2003
To e filed in person or by mail with the County Auditor of the counry where the properiy is located.
Filing Dates: 1) Real Property: During the 12 months before Mey 11 0/ the year the deduction is to be eHective.
2J Mobile Homes assessed under IC 6-1.1-7: During the 12 months be(ore March 2 o,�f,ze�a�ch �y�e�a-�� fhj,e• in�idual �w,ish,q,p�to
obtain the deduction. /a " •�� .%
See reverse side (or additional instructions and ualifica[ions. GIBSON COUNTY AUDITOR 1
Name of appliwnt (owner or contrect buyer) _
appflcant tna soie iegai or
name on record is difteren
ame of conVact seller
ddress ot conVact seiler
Yes ❑ No
blind as defined in IC 1
❑ Yes C�'I�
and oaupied primarily for hislh
es ❑No
�hat is h7slFier exact sR�1'� of interest? if owned wiih someone other than spouse,
indicate with whom
below
Is tha property in question:
❑ Real Property ❑ Mobile Hame (IC
2-12(b)? Is applirant disabled and unable to engage in any substantial gainful e
as defined in IC 6-1.1-12(d)?
es ❑ No
ance? Does the aDPlicanPs taxable gross income for the preceding caiendar
exceed 517,000? /
❑ Yes C�,PI�
mber I Leaal descriolion Record number Page number
E1.1
year
IM1e certify under penalty of perjury Ihat the above and foregoing infortnation is Irue and correct and that the applicani was a resident
of Indiana and owner of the aforementioned property on March 1, 20 _
Signa�
��
of applicant